Commonwealth of Learning



Unit 4: HIV Associated Conditions

A distance learning course offered by the AMREF Directorate of Learning Systems

© 2007

African Medical Research Foundation (AMREF)

This course is distributed under the Creative Common Attribution-Share Alike 3.0 license. Any part of this unit including the illustrations may be copied, reproduced or adapted to meet the needs of local health workers, for teaching purposes, provided proper citation is accorded AMREF. If you alter, transform, or build upon this work, you may distribute the resulting work only under the same, similar or a compatible license. AMREF would be grateful to learn how you are using this course and welcomes constructive comments and suggestions. Please address any correspondence to:

The African Medical and Research Foundation (AMREF)

Directorate of Learning Systems

P O Box 27691 – 00506, Nairobi, Kenya

Tel: +254 (20) 6993000

Fax: +254 (20) 609518

Email: amreftraining@

Website:

Writer: Dr Jared Mecha

Cover Design: Bruce Kynes

Technical Co-ordinator: Joan Mutero

The African Medical Research Foundation (AMREF) wishes to acknowledge the contributions of the Commonwealth of Learning (COL) and The Allan and Nesta Ferguson Trust whose financial assistance made the development of this course possible.

Contents

UNIT 4: HIV Associated Conditions 1

INTRODUCTION 1

Unit Objectives 1

Section 1: Introduction To HIV-Associated Conditions 2

Introduction 2

Objectives 2

Opportunistic Infections 2

Risk Factors For Opportunistic Infections 4

Major Causes of HIV Related Infections 6

Prevention of Opportunistic Infections 7

Summary 11

Section 2: Common Conditions of the Nervous System in HIV/AIDS 12

Introduction 12

Section Objectives 12

Neurological Disease During The Acute Sero-Conversion Illness 13

Neurological Disease During The Early Symptomatic Phase of HIV 16

Neurological Conditions Caused By Protozoal Agents 19

Neurological Conditions Caused By Bacteria 21

Neurological Diseases Caused By Fungal Agents 23

Painful Sensory and Motor Peripheral Neuropathies 26

Other Conditions 28

Summary 31

Section 3: Common Conditions Of The Gastrointestinal System in HIV/AIDS 32

Introduction 32

Section Objectives 32

Diarrhoea In HIV Infection 34

Common Causative Organisms of Diarrhoea in HIV Infection 35

Oral Lesions In HIV/AIDS 38

Weight Loss and HIV Wasting Syndrome 42

Summary 45

Section 4: Common Conditions of the Respiratory System in HIV/AIDS. 46

Introduction 46

Section Objectives 46

Common Respiratory Conditions in HIV/AIDS. 47

Upper Respiratory Tract Infections 48

Lower Respiratory Tract Infections 50

Tuberculosis: HIV/TB Interaction 54

Summary 64

Section 5: Common Conditions of The Skin in HIV/AIDS 65

Introduction 65

Section Objectives 65

Skin Conditions Relating To HIV Infection 66

SCALY RASHES 67

FUNGAL SKIN INFECTIONS 69

DRY SKIN 69

NON ITCHY PAPULES AND NODULES 70

ITCHY PAPULES 71

BLISTERS AND EROSIONS 73

DRUG REACTION 75

TUMOURS ASSOCIATED WITH HIV/AIDS 76

Summary 80

Abbreviations

AIDS Acquired Immune Deficiency Virus

ART Antiretroviral therapy

ARV Antiretroviral

BID, BDS Twice a day

CBC Complete Blood Count

CNS Central nervous system

CPK Creatinine phosphokinase

CSF Cerebrospinal fluid

CSF-CRAG Cerebrospinal fluid-cryptococcal antigen test

CT Computerized tomography

CXR Chest x-ray

DAART Directly Administered ART Therapy

DOT Directly observed treatment

DOTS Directly observed treatment strategy

DS Double strength

DTC Diagnostic Testing and Counselling

DS Double Strength

EBV Epstein-Barr virus

EFZ Efavirenz

EHRZ ethambutol (E), isoniazid (H), rifampicin (R), pyrazinamide (Z)

FBC Full blood count

GI Gastrointestinal

HAART Highly active antiretroviral therapy

HAD HIV-associated dementia

HAV Hepatitis A virus

HbcAb or AHBC Hepatitis B core antibody

HCV Hepatitis C virus

HDV Hepatitis D virus

HHV Human herpes virus

HR Isoniazid (H), Rifampicin (R)

HRE Isoniazid (H), Rifampicin (R), Ethambutol (E)

HRZ Isoniazid (H), Rifampicin (R), Pyrazinamide (Z)

HRZE Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), Ethambutol(E)

HIV Human Immunodeficiency Virus

HSR Hypersensitivity reaction

HSV Herpes simplex virus

IEC Information Education and Communication

IDU Intravenous drug use

IMCI Integrated Management of Childhood Illnesses

IV Intravenous

KS Kaposi’s sarcoma

LIP Lymphoid interstitial pneumonia

MAC Mycobacterium avium complex or M.avium complex

MTCT Mother to Child Transmission

NHL Non-Hodgkin’s lymphoma

NVP Nevirapine

OD Once a day

OIs Opportunistic Infections

OPC Oropharyngeal candidiasis

PCP Pneumocystis Carinii Pneumonia

PGL Persistent generalized lymphadenopathy

PLWHA People Living With HIV/AIDS

PO Per oral or medication administered by way of mouth

PID Pelvic infl ammatory disease

PML Progressive multifocal leukoencephalopathy

QDS,QID Four times a day

STI Sexually transmitted infection

SS Single Strength

TB Tuberculosis

TDs Three times a day

VCT Voluntary Counselling and Testing

WHO World Health Organisation

UNIT 4: HIV Associated Conditions

INTRODUCTION

Welcome to the fourth unit of this course on Integrated HIV/AIDS prevention, treatment and care. In the last unit we discussed counselling and psychological care. I hope that you are now well armed to provide basic HIV testing and counselling services to your clients. In this unit we shall discuss some of the common conditions associated with HIV/AIDS.

This unit is made up of the following 7 sections:

Unit 1: Introduction to HIV associated conditions

Unit 2: Common conditions of the Nervous system in HIV/AIDS

Unit 3: Common conditions of the gastrointestinal system in HIV/AIDS

Unit 4: Respiratory manifestations of HIV/AIDS

Unit 6: Common conditions of the Skin (including tumours) in HIV/AIDS

Unit Objectives

By the end of this unit you should be able to:

• List the opportunistic conditions associated with HIV/AIDS;

• Describe why PLWAs are susceptible to opportunistic conditions;

• Explain the relationship between immune deterioration and occurrence of opportunistic infections;

• Describe the common presentations of opportunistic conditions;

• Discuss the treatment and prevention of common opportunistic conditions;

• Discuss the symptomatic management of HIV disease

Welcome!

Section 1: Introduction To HIV-Associated Conditions

Introduction

Welcome to the first section of our unit on HIV-associated conditions. In this section we shall start by defining opportunistic infections and look at their risk factors and common causes. Let us start by looking at our objectives for this section.

Objectives

By the end of this section you should be able to:

• Define opportunistic infections

• Discuss the risk factors for opportunistic infections

• Describe their common causes.

We shall begin by looking at the definition of opportunistic infections.

Opportunistic Infections

As we learnt in Unit 1 of this course, the human immunodeficiency virus (HIV) weakens the human immune system by attacking CD4 cells, which defend the body against infection. This causes progressive destruction of the immune system, until the infected person is unable to fight infection. Early in HIV infection, the infected person is normally healthy or may have minor conditions like skin rashes, a little weight loss or repeated sinusitis. During later stages of HIV infection, the immune system becomes very weak. The patient begins to get diseases which under normal conditions their body could easily fight off. These diseases are called Opportunistic Infections (OIs) or HIV-associated conditions.

|[pic] | |

| |Why are these diseases called opportunistic infections? |

HIV-associated conditions are called opportunistic infections because they take advantage of a weakened immune system to cause disease. These diseases do not normally affect a person with a normal immune system. They are only severe and more frequent in HIV infected people. The natural history of HIV involves a progressive loss of CD4 lymphocytes (see Figure 1.1 below). As the CD4 level declines, the risk of contracting OIs increases.

Key: CD4 cells HIV

|[pic] |

|Beginning: skin diseases, minor loss of weight... |After 7-10 years: chronic diarrhoea, chest problems, |

| |other opportunistic infections. |

Figure 4.1: Progressive loss of CD4 cells in HIV (Source: MOH, 2006: Manual for Comprehensive Management of HIV Infection)

Risk Factors For Opportunistic Infections

People with HIV are particularly susceptible to opportunistic infections for the following reasons:

• Weakened immunity i.e. low CD4 cell counts;

• Malnutrition;

• Psychological stress;

• Failure to seek medical care promptly;

• Poor personal hygiene;

People with a normal immune system have CD4 cell counts of between 380 to 1500 cells per millilitre. When the CD4 cell count drops below 380 cells/mL, the person begins to get minor infections like skin infections, seborrhoea, herpes zoster, prurigo etc;

A person with a CD4 cell count less than 200 cells/mL can get serious opportunistic infections like disseminated and extra-pulmonary tuberculosis, cryptococcal meningitis, pneumocystis carinii pneumonia (PCP), toxoplasma encephalitis, among others.

Co-infection with pathogens such as TB and malaria increases the HIV viral burden and thus accelerates the disease progression. Therefore, preventing other infections such as STDs, malaria and TB can be of great benefit to a HIV positive person.

Most morbidity and mortality in HIV/AIDS is caused by opportunistic infections. Most opportunistic infections are preventable and/or treatable using simple and affordable strategies.

Figure 4.2 below shows the risk of occurrence of various opportunistic infections as body immunity (measured by CD4 cell counts) deteriorates.

Early disease ::::::::::::::::::::::::> Advanced disease-(Death

|CD4 cell count | |

|(Cells/ml) | |

|800 | |Lymphadenopathy |

| | |Thrombocytopenia |

|600 | |Minor skin infections |

| | |Respiratory tract infections |

| | |Herpes simplex/ herpes zoster |

|400 | |Oral thrush, PTBa |

| | |Kaposi’s sarcoma |

| | |Tuberculosis |

|200 | |PCPb, Cryptococcosis, severe herpes ulcers, |

| | |oesophageal candidiasis |

|0 | |Toxoplasmosis, Extrapulmonay TB |

| | |Lymphoma, CMVc, MACd. |

Time: Months......../ /......................................................................Years

aPTB: Pulmonary tuberculosis bPCP:Pneumocystis carinii pneumonia

cCMV:Cytomegalovirus dMAC:Mycobacterium avium complex

Figure 4.2: Approximate Correlation Of Risk Of Opportunistic Infection And Immune Function Deterioration

After about 5 to 10 years, the patient becomes very sick and develops the Acquired Immune Deficiency Syndrome i.e. AIDS.

Major Causes of HIV Related Infections

HIV related infections are caused by different pathogens, including bacteria, fungal agents, viruses and protozoal agents. Table 4.1 below outlines the major causes of infections in different parts of the body..

Table 4.1: Major causes of HIV related diseases

|Brain |Toxoplasmosis (Toxo) |

| |Cryptococcal meningitis |

|Eyes |Cytomegalovirus (CMV) |

|Mouth & Throat |Candidiasis (Yeast) |

|Lungs |Pneumocystis carinii pneumonia (PCP) Tuberculosis (TB) |

| |Histoplasmosis |

|Gut |Cytomegalovirus (CMV) |

| |Cryptospridiasis |

| |Mycobacterium avium complex (MAC) |

|Skin |Herpes simplex |

| |Shingles |

|Genitals |Genital Herpes |

| |Human papillomavirus (HPV) |

| |Vaginal Candiadiasis (Yeast) |

|[pic] | |

| |Many opportunistic infections can be prevented through simple measures like hand washing after visiting the |

| |toilet and before handling food, drinking clean, boiled or treated water, cooking milk and meat properly before |

| |eating and washing fruits and vegetables well before eating. |

How else can we prevent opportunistic infections? Lets look at that next.

Prevention of Opportunistic Infections

Another way that is now commonly used to prevent opportunistic infections is the use of prophylaxis. Before you read on do the following activity.

|[pic]ACTIVITY |

| |

|What is prophylaxis |

|_____________________________________________________________________ |

|_____________________________________________________________________ |

|_____________________________________________________________________ |

|_____________________________________________________________________ |

Now compare your answer with the following definition of prophylaxis drawn from . Prophlylaxis is any procedure whose purpose is to prevent, rather than treat or cure, disease. Roughly, prophylactic measures are divided between primary prophylaxis (to prevent the development of a disease) and secondary prophylaxis (whereby the disease has already developed and the patient is protected against worsening of this process).

In persons infected with HIV, we give prophylaxis in order to decrease their risk of developing some opportunistic infections that can be fatal. A good prophylaxis also helps to increase the duration and quality of life of a person infected with HIV. The most commonly used prophylaxis is cotrimoxazole prophylaxis.

Cotrimoxazole (CTX), also known as Sulfamethoxazole-Trimethoprim (SMX-TMP), is a broad spectrum antimicrobial agent that targets a variety of aerobic Gram-positive and Gram-negative organisms and protozoa. The drug is widely available in both syrup and solid formulations at low cost in most places, including resource-limited settings.

According to WHO guidelines, cotrimoxazole prophylaxis should be used by people with progressing HIV disease and by all HIV-infected or exposed infants (until it is clear that they are uninfected). Cotrimoxazole has been found to be effective in reducing the risk of the following opportunistic infections:

• Pneumocystis pneumonia (PCP) (the germ causing this peumonia used to be called Pneumocystis carinii but is now called Pneumocystis jiroveci): The prognosis of this type of pneumonia is often bad especially if diagnosis is delayed or effective treatment is not provided. You will learn more about it later in this unit;

• Toxoplasma brain abscess: this disease can cause hemiparesis (one side of the body is weak or cannot move anymore), often together with headache and fever.

• Malaria;

• Bacterial pneumonia;

• Diarrhoea.

As you can see from the above list, the initiation of cotrimoxazole can greatly increase the quality of life of a HIV-infected person.

What’s the Criteria for Starting Cotrimoxazole Treatment?

According to the Kenya Ministry of Health guidelines, all HIV positive people regardless of WHO stage or CD4 count should be started on cotrimoxazole prophylaxis unless contraindicated. They should also continue taking it whether or not they are on Antiretroviral therapy. This is referred to as primary prophylaxis (prevention provided before development of the disease). Before you put a patient on CTX, you should first ask about a previous history of sulpha allergy. If the patients reports any allergy they should not be given cotrimoxazole.

Drug Regimen for CTX Prophylaxis

According to the Kenya National ART guidelines, all HIV-exposed children should be started on cotrimoxazole at at 6 wks or when first seen.

← A child is said to be exposed to HIV infection:

o If they are born to woman confirmed to be HIV-positive and are < 18 months of age and they have not had a PCR test done

OR

o The child is < 18 months of age and has a positive HIV antibody test and they have not had a PCR test

OR

o The child is breastfeeding at any age and their mother is confirmed to be HIV positive.

In the case of HIV-infected children, you should start CTX routinely in all HIV-infected children regardless of age, immune status or treatment status.

Dosage

Cotrimoxazole syrup is administered once daily. If syrup is unavailable, paediatric tablets may be used or adult tablets can be split appropriately as shown below. You may switch from syrup to tablets to ensure continuous access to medication.

Table 4.2: Cotrimoxazole (trimethoprim-sulfamethoxazole or TMP/SMX) dosages

|Weight of |240 mg per 5 ml Suspension| Single Strength (SS) Tablets 480 |Double Strength (DS) Tablets 20mg/100mg |

|child (Kg) | |mg | |

|1-4 | 2.5 ml |¼ tablet | |

|5-8 |5 ml |½ tablet |¼ tablet |

|9-16 |10 ml |1 tablet |½ tablet |

|17-30 |15 ml |2 tablets |1 tablet |

|>30 |20 ml |2 tablets |2 tablets |

Cotrimoxazole prophylaxis should be continued indefinitely.

In adults, the drug regimen for CTX prophylaxis is as follows:

• Cotrimoxazole 480mg, 2 tables daily

OR

• Cotrimoxazole 960mg, 1 table daily

Cotrimoxazole Prophylaxis Side Effects

Cotrimoxazole is well tolerated in most patients. However, cccasionally side effects may occur, most of which are relatively mild.

If a patient develops any of these side effects, CTX should be stopped and the patient referred to a clinician for further management. These side effects include:

• Steven-Johnsons reaction: a very severe drug reaction that can be fatal if not recognised. It presents with a rash that involves the eyes and mucosa of the mouth and genital area. The skin lesions can look like burns with blistering and peeling.

• Fixed drug reaction: one or several dark areas on the skin. They disappear when the drug is stopped. They reappear on the same location when restarting the drug.

• Other new generalised drug rashes: If the patient has peeling or involves the eye or mouth or are associated with fever, stop and refer. If there is no peeling, no fever and no eye or mouth involvement, just stop the drug. Follow-up the next day.

• Liver failure: you can detect this if the patient appears with jaundice (yellow colour of the white of the eyes). Stop all drugs. Call for advice or refer.

• Haematological failure: in rare cases, cotrimoxazole can suppress the bone marrow. The bone marrow is responsible for making new blood. This can present in several ways:

← The patient develops severe anaemia (looking pale or having low haemoglobin), and/or

← The patient develops a decrease in white blood cells (leading to infections) and/or

← The patient develops easy bleeding due to a decrease in blood platelets, which are responsible for clotting of the blood.

← Cotrimoxazole should be stopped in severe cases of bone marrow suppression

Monitoring Patients On Cotrimoxazole Prophylaxis

In the beginning, you should follow-up the patient every month. Later, if no problems occur and if the patient takes the drugs correctly, follow-up can be done every 3 months.

Follow-up visits should include clinical assessment for side effects and education of the patient on the importance of continuing to take the drug as adviced.

In order to prepare the patient for CTX and to follow them up properly you should use the 5As which stand for Assess, Advise, Agree, Assist, Arrange.

• Assess the patient’s for symptoms and signs, classify the illness and decide on what treatments to recommend.

• Advice by educating and preparing the patient for self management.

• Agree: ensure that the patient understands and wants the treatment and that he or she agrees to the Treatment Plan.

• Assist the patient by giving education, advice and counselling, and also by helping them in terms of skills to take their treatment correctly and to overcome any barriers to treatment adherence.

• Arrange a follow-up date or how the medication can be picked up on the next visit

Attending clinic regularly for scheduled visits (adherence to care) and adhering to daily cotrimoxazole prophylaxis are good preparation for ART. These visits also provide the opportunity to monitor the patient’s WHO stage and their medical eligibility for ART.

Summary

In this section you have learnt about opportunistic infections in HIV/AIDS, their definition, risk factors and common causes and prevention. In the next section we shall look at the common conditions that affect the nervous system.

Section 2: Common Conditions of the Nervous System in HIV/AIDS

Introduction

Welcome to the second section of our unit on diagnosis, management and prevention of common HIV associated conditions. In this section we shall look at common conditions that affect the nervous system. The aim of this section is to introduce you to the different ways in which HIV can affect the nervous system. HIV infects the central nervous system very early in the course of HIV infection. Up to 10% of patients may experience neurological disease during the primary illness. If they are not treated (with highly active antiretroviral therapy (HAART), 40-50% of patients will develop a neurological disease as a result of HIV infection. Most of the neurological diseases associated with HIV are treatable with readily available medicines. That is why it is very important to be able to diagnose them promptly.

Section Objectives

By the end of this section you should be able to:

• Recognize a patient presenting with neurological diseases;

• Outline the diagnosis, investigations and treatment of neurological disease in HIV/AIDS;

• Identify the medical/nursing care issues associated with the care of these patients.

In section one of this Unit we mentioned that HIV related infections are caused by different pathogens. Can you remember which ones we mentioned

Start by doing the following activity. Find out by doing the following activity.

|[pic]ACTIVITY |

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|List the different pathogens that cause opportunistic infections in HIV. |

| |

|_____________________________________________________________________ |

|_____________________________________________________________________ |

|_____________________________________________________________________ |

|_____________________________________________________________________ |

|_____________________________________________________________________ |

|_____________________________________________________________________ |

I believe you mentioned that the pathogens may be viral, bacterial, fungal or protozoal agents.

We shall start our discussion by looking at the common conditions during the acute sero-conversion illness (1-6 weeks) and early symptomatic stage after infection with HIV. Then we shall look at other conditions of the nervous system divided according to the pathogens that cause them.

Neurological Disease During The Acute Sero-Conversion Illness

The acute seroconversion illness occurs 1-6 weeks after infection with HIV. The neurological complications during this period include:

• Headache;

• Meningitis;

• Encephalitis;

• Movement disorders or unsteady gait (ataxia);

• Cranial and peripheral neuropathy;

• Myopathy.

Let us look at each in turn.

Headache

Headache is a common presentation during primary HIV infection, occurring in up to 30% of patients. It may be associated with other signs of meningitis, see Table 4.3 below.

Acute Meningitis

Acute meningitis which comes during the acute sero-conversion illness stage is due to inflammatory response to the presence of HIV in the central nervous system. Patients present with symptoms of meningitis such as those outlined in Table 1.1 below, which develop over a short period of time (less than one week). The headache can be very severe, and they tend to keep their necks still. Remember that a patient with acute meningitis during the seroconversion illness is generally well nourished, may have a rash and this might be his first presentation to a health facility. If possible, obtain history of possible recent high exposure to HIV.

Table 4.3 Symptoms of meningitis

|Fever |

|General weakness and drowsiness |

|Vomiting |

|Headache |

|Photophobia |

|Neck stiffness |

Diagnosis is made by doing a lumbar puncture (unless contra-indicated). About 10 ml of Cerebral Spinal Fluid (CSF) are sent to the laboratory where the following parameters are assessed:

• Glucose

• Protein

• White cell counts

• Gram stain (for ordinary bacteria like Neisseria meningitidis, Streptococcus pneumoniae and Haemophilus influenzae); acid fast bacteria for Mycobacteria tuberculosis and India ink stain for Cryptococcus neoformans.

• Mycobacterial, bacterial and fungal cultures

Normally, no abnormality is found in the CSF or there may be a slight increase in mononuclear cells, i.e. the CSF is aseptic, thus the term aseptic meningitis.

Treatment

Treatment is symptomatic, with analgesics such as paracetamol 1g 6-8 hourly in adults or ibuprofen 400 mg 8 hourly or both if not controlled on one of them. The patient normally recovers in one week.

Acute Encephalitis

This is a condition that results from direct invasion of the brain substance by HIV or due to the immune response to HIV as a result of HIV in the brain. It occurs soon after infection (in the first 1-6 weeks) in a previously healthy individual. The patients present with acute onset fever, weakness, lethargy and there may be a rash. It is characterized by symptoms and signs of abnormal cerebral function (Table 4.4 below).

Table 4.4: Signs and symptoms of abnormal cerebral function

| |

|Altered level of consciousness from disorientation, delirium to coma |

|Personality change such as anxiety, restlessness, mania or frank psychosis |

|Convulsions |

|Stroke |

Diagnosis

These patients require a lumber puncture. A CT scan may be necessary to exclude intra-cerebral mass lesions such as those caused by Toxoplasma gondii.

Management

Unlike aseptic meningitis, acute encephalitis is a serious condition. The following therapeutic strategies should be employed:

• Admission and close monitoring;

• Adequate hydration and nutrition;

• Analgesics and antipyretics;

• Anticonvulsants and anti-psychotics.

With proper supportive management the patient is able to recover well from this condition.

Myopathy

Myopathy simply means a disorder of muscle tissues and muscles. Patients with acquired immunodeficiency syndrome (AIDS) may experience severe wasting from repeated infections, malignancy, malabsorption, and nutritional deficiency. Muscle weakness may also be due to central and peripheral nervous system involvement from infections or immunologically mediated neuropathies in these patients . However, the possibility of skeletal muscle disease should not be overlooked since several specific skeletal muscle disorders that cause weakness have been identified in HIV-infected patients. Myopathy may also be induced by Zidovudine, a drug used in the treatment of HIV infections. So you should suspect zidovudine induced myopathy in all patients who develop characteristic clinical features in the setting of months of AZT therapy.

Neurological Disease During The Early Symptomatic Phase of HIV

When HIV infection reduces the number of CD4 cells to around 200 per microlitre of blood, the infected individual enters an early symptomatic phase that may last a few months to several years.

The following neurological diseases may occur during the early symptomatic stage of HIV infection are:

• Peripheral neuropathy (PN)

• Guillian-Barre syndrome

Peripheral Neuropathy (PN)

Peripheral neuropathy simply means damage to nerves of the peripheral nervous system. Peripheral nerves can be either motor or sensory or autonomic. Patients with autonomic neuropathy present with sensory, motor or autonomic symptoms as shown in Table 4.5 below.

Table 4.5 Symptoms of peripheral neuropathy

| |Symptoms |

|Sensory symptoms |Numbness, pins and needles , burning sensations, pain provoked by|

| |light touch, temperature stimulation (hyperalgesia) |

|Motor symptoms |Weakness and wasting of the limbs |

|Autonomic symptoms |Very dry, scaly skin, loss of hair |

The hands are often spared in peripheral neuropathy. The symptoms are symmetrical, i.e. the both limbs are affected concurrently. You should always exclude drugs as the cause of the symptoms. Drugs such as isoniazid (used in the management of TB), stavudine and didanosine (both ARVs) and dapsone can cause peripheral neuropathy. Excess alcohol intake and vitamin B12 deficiency can also cause PN.

In order to provide effective treatment, it is essential to distinguish among the various forms of neuropathy and to correctly attribute them to primary HIV infection or to other causes, such as the neurotoxic effects of antiviral agents. Although peripheral neuropathy is generally not a life-threatening disease, the debilitating pain can severely impair the quality of life of the affected individuals.

Treatment

Where a known noxious agent can be identified, this should be removed. Patients who are TB/HIV co-infected on anti-tuberculous therapy should receive pyridoxine supplementation. Antidepressants such as imipramine, and analgesics are helpful. The anti-depressants should be given for a long time to provide relieve.

Guillian-Barre Syndrome

This is a severe form of neuropathy caused by de-myelination i.e. removal of the insulating covering of nerves. It is characterized by worsening muscle weakness initially in the lower limbs and progressing upwards. The face, arms and muscles that control breathing and swallowing may also be involved.

Treatment

The disease may progress rapidly to involve muscles that control breathing. The patient should be admitted or referred to a facility that can offer respiratory support (invasive ventilation). Meanwhile, the care of such a patient should include the following:

Careful monitoring (check peak expiratory flow rate and respiration, monitor oxygen saturation) and other vital signs;

• Maintain a patent airway;

• Nutrition;

• Adequate hydration;

• Bladder and bowel care;

• Prevention of pressure sores;

• Physiotherapy .

Having discussed the neurological diseases which may occur within the first 6 weeks and early symptomatic phase of HIV infection, let us now look at neurological conditions according to their causative agents. We shall start with those that are caused protozoal agents.

Neurological Conditions Caused By Protozoal Agents

Toxoplasma Encephalitis

Start by doing the following activity.

|[pic]ACTIVITY |

| |

|What causes toxoplasma encephalitis? |

|_____________________________________________________________________ |

|_____________________________________________________________________ |

|_____________________________________________________________________ |

|_____________________________________________________________________ |

|_____________________________________________________________________ |

Now confirm your answers as you read the following discussion.

Toxoplasma encephalitis is caused by a protozoan Toxoplasma gondii. This is a single-celled parasite that causes toxoplasmosis. Of those who are infected, very few have symptoms because a healthy person's immune system usually keeps the parasite from causing illness. However, those with a CD4 count of less than 100/ml are at highest risk. Patients complain of having been feeling unwell for the last 2 to 4 weeks. Cerebral toxoplasmosis is one of the most common HIV-related neurological complications. If patient does not receive maintenance therapy, cerebral toxoplasmosis will recur.

Signs and Symptoms

Patients complain of fever, headache (severe, localized), confusion, myalgia, arthralgia, focal neurological defects such as seizures, convulsiosions, cerebellar tremor, cranial nerve palsies, hemisensory loss, visual problems or blindness, personality changes and cognitive disorders.

Diagnosis

Making a diagnosis of toxoplasmosis in a peripheral rural health facility is difficult and so diagnosis is based on clinical symptoms. However where facilities allow you can carry out a CT scan or MRI Toxoplasma IgG titers. CT scan or MRI will show lesions in the cerebral hemispheres;

Treatment

If any patient who is HIV+ presents with fever, headache, focal neurological deficits and a normal CSF findings, they should receive empiric therapy for toxoplasmosis.

Start anti-convulsant treatment:

Epanutin 50-100 mg bid or tid; or tegretol 100-200 mg bid or tid (to be started only if the patient has convulsion)

Treatment for acute phase

• Pyrimethamine 100-200 mg loading dose, then 50-100 mg/day po + folinic (or folic) acid 10 mg/day po + sulfadiazine 1-2 g qid for at least 6 weeks

• OR

• Trimetrpim/sulfamethoxazole 10/50mg/kf daily for weeks

• OR

• Clindamycin (600mg tid) + pyrimehamine 100mg daily loading dose followed by 50mg daily +folinic acid 10 mg daily

Preferred regimen for suppressive therapy required after a patient has had Toxo:

• Pyrimethamine 25-75 mg po qd + folinic acid 10 mg qd +sulfadiazide 0.5-1.0 gm po qid if allergic to sulfa

• Give dapsone po 100 mg po once daily or clindamycin IV (or oral) 600 mg qid or atovaquine 750 mg po qid

During treatment, advise patients to maintain a high fluid intake and urine output.

Check blood picture regularly as the relatively high doses of drugs can lead to toxicities. Leukopenia, thrombocytopenia and rash are common. Folinic acid reduces the risk of myelosuppresion.

Neurological Conditions Caused By Bacteria

Tuberculous Meningitis

Before you read on do the following activity. It should take you 5 minutes to complete.

|[pic]ACTIVITY |

| |

|What is tuberculosis? |

|_____________________________________________________________________ |

|_____________________________________________________________________ |

|_____________________________________________________________________ |

|_____________________________________________________________________ |

|_____________________________________________________________________ |

Tuberculosis is an infectious disease caused by a bacillus called Mycobacterium tuberculosis, an acid-fast rod shaped bacillus. The bacillus is transmitted from person through aerosolized droplet nuclei and therefore coughing, which generates infected droplets, is the most important mode of transmission of TB. The bacillus may also be transmitted by other aerosol generating processes including laughing, talking, sneezing, singing and spitting.

Tuberculosis can attack any organ of the body such as the lymph nodes, urinary tract (kidney, ureters, bladder), the genital system (ovary, fallopian tubes, uterus, testes, epididymis, skeletal system (bone, joints), the nervous system (brain, meninges, spinal cord), the skin, the eye, the gastrointestinal system and serosal membranes (peritoneum, pleura, pericardium). When TB occurs outside the lung it is said to Extra-Pulmonary (EPTB).

Tuberculosis mengtitis is a severe form of tuberculosis that affects the meniges in the brain. Up to 10% of PLWHAs who have TB have involvement of the meninges. Patients are often unwell for several weaks before presenting to hospital. At presentaion they complain of headache, decreased consciousness, low-grade fever, neck stiffness and positive Kernig’s sign.

Diagnosis

Diagnosis is made by having a high index of suspicion and doing a lumber puncture. The lumber puncture often shows:

• a cloudy CSF;

• WBC count 500/ml mainly lymphocytes (in the early phase granulocytes might predominate);

• high protein level (40 mg/dl-100 mg/dl);

• low glucose level ( 1 cm diameter may be deep. Usually heal very slowly, cause severe pain and may affect feeding.

Treatment:

Prescribe a topical therapy 2 to 4 times a day such as:

• Lignocaine solution before meals OR

• 250 mg tetracycline tablet in 15 cc water, gargled for a few minutes (should not be swallowed) OR

• a solution of 1 mg hydrocortisone + Nystatin 8400 IU + tetracycline 84 mg + 5 ml viscous lignocaine gargled 4 x daily ( can be swallowed)

You can also give systemic therapy such as Prednisone 40 mg/day PO for 1 week.

People with Aphthous ulcers may reduce their oral food and fluid intake because of the associated pain and subsequently become dehydrated; therefore, aggressive therapy for the lesions is very important.

Weight Loss and HIV Wasting Syndrome

Involuntary weight loss is a common condition associated with advancing HIV disease and gastrointestinal symptoms. According to the Centre for Disease Control (CDC) wasting is classified as an AIDS diagnosis when a patient presents with involuntary weight loss of more than 10% of baseline body weight, plus either chronic diarrhea or chronic weakness and fever in the absence of infection or a condition other than HIV disease. Wasting syndrome accounted for 20% of AIDS-defining diagnoses in 1995.

If a patient continues to progressively lose weight, death is inevitable once body weight falls below roughly 66% of ideal body weight.

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Figure 3.1: HIV wasting syndrome

Weight loss above 5 to 10% from usual weight predicts mortality, independent of CD4 count.

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|What are the causes of involuntary weight loss in HIV/AIDS? |

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Now confirm your answers as you read the following discussion.

Involuntary weight loss can be classified into two different etiologies:

• caloric deficit and ;

• metabolic disturbance.

Inadequate caloric intake and weight loss may be due to upper intestinal abnormalities (anorexia, nausea, vomiting), psychosocial and economic factors, fatigue, mental status changes, and medications. Patients frequently reduce their oral intake to reduce symptoms of diarrhea or abdominal pain. Thus the body undergoes an adaptive process whereby it selectively utilizes body fat stores for energy in order to preserve lean body mass (starvation model). In contrast, metabolic disturbances are brought about by conditions such as opportunistic infections which increase energy requirements. This results in a disproportionate loss of lean body mass with relative preservation of body fat stores.

Caloric deficit is one cause of weight loss that may be due to odynophagia, dysphagia, anorexia, altered sense of taste, early satiety, nausea, vomiting, diarrhea, fever, fatigue, apathy and/or depression. Pharmacologic side effects, opportunistic infections that result in lesions in the mouth or esophagus, and malabsorption of nutrients can be the underlying causes of reported symptoms. Self-restriction of caloric intake to reduce diarrhea, nausea, and vomiting is also common among patients.

All patients infected with HIV should have a regular nutritional and functional assessment. Weight loss, body composition changes, and exercise/functional limitations are indicators of advancing disease that may be reversible. All patients who have lost weight should have a thorough evaluation for symptoms contributing to inadequate intake. You should then promptly initiate interventions to promote weight gain. When assessing a patient with involuntary weight loss, you should try to identify markers and predictors of malnutrition. A careful review of symptoms will identify barriers to adequate oral intake such as, anorexia, early satiety, dysgeusia, nausea, vomiting, weakness/fatigue, odynophagia, dysphagia, poor dentition, diarrhea, and abdominal pain. In addition, conditions that increase energy requirements should also be noted, including: fever, tachypnea, systemic infections, increased physical activity. When taking history you should also find out about the use of medications and "alternative therapies" (including herbal therapy and megadosing of vitamins and minerals) which may provide insight into potential side-effects. Remember to also take a social history in order to identify environmental or financial obstacles to obtaining, storing, and preparing food.

Summary

In this section you have learnt about common gastroinstestinal infections in HIV/AIDS. I hope you are now well equipped to diagnose and manage these infections, In the next section we shall discuss respiratory manifestations of HIV.

Section 4: Common Conditions of the Respiratory System in HIV/AIDS.

Introduction

Welcome to section four of our unit on HIV associated conditions. In the last section we discussed common conditions of the gastrointestinal system. In this section we shall look at conditions of the respiratory system. Respiratory disease is a major cause of disease and death in HIV infection. Approximately 70% of HIV infected patients will have a respiratory disorder in the course of their illness. For this reason, you will find that often a diagnosis of HIV infection is made when a patient seeks medical attention of respiratory symptoms.

Let’s start by looking at our objectives for this section.

Section Objectives

By the end of this section you should be able to:

• Identify the common respiratory conditions associated with HIV infection;

• Explain their diagnosis;

• Describe the management of respiratory disease in HIV;

• Discuss the interaction between HIV and tuberculosis.

Common Respiratory Conditions in HIV/AIDS.

Before you read on do the following activity. It should take you 5 minutes to complete.

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|List down the common respiratory conditions in people with HIV/AIDs |

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Now compare what you wrote down with the information given in Table 4.9 below.

Table 4.9: Common Respiratory Conditions in HIV/AIDS

|Early HIV disease |Sinusitis |

|CD4 > 500 cells/ml |Bronchitis |

| |Bacterial pneumonia |

| |Pulmonary tuberculosis |

|Moderate immunosuppression |PCP |

|CD4 100-200 cells/ml |KS |

| |Disseminated KS |

|Severe Immunosuppression |Fungal infections |

| |Non-tuberculous mycobacteria |

Infections of the respiratory system may be divided into those of the upper and of the lower tract. Let us start by looking at those of the upper respiratory tract.

Upper Respiratory Tract Infections

These include the following:

• Sinusitis

• Pharingitis

• Otitis external

• Otitis media

We shall now discuss each in turn.

Sinusitis.

This refers to inflammation of the sinuses and is usually due to infection. In the HIV positive patient, sinusitis occurs at all stages, but is most common among those in Stage 4 disease.

Patients present with non-specific symptoms of headache, commonly intense over the face, and which is worsened by leaning forward. They may also have pain in the upper jaw if the maxillary sinus is involved. Running of the nose is also common and may be attributed to a common cold. Indeed, viral infection of the nasal passages often occurs before the sinusitis.

The organisms commonly causing this infection are S. pneumonia and H. influenza. P. , but aeruginosa may also be found. Bacterial sinusitis where symptoms are of less than 4 weeks old can be effectively treated with Amoxicillin 500mg TID for 10 days or co-trimoxazole 960 mg twice daily for 10 days.

Pharyngitis

S. pneumonia is the most common causative organism in most of the patients with pharyngitis of acute onset. Infection by S. pyogenes can lead to rheumatic fever and to glomerulonephritis especially in the patient who is below the age of 15 years. Other bacterial causes of pharyngitis are Neisseria meningitides, or sexually transmitted bacteria like Treponema pallidum or Neisseria gonorrhoea.

Patients present with fever, swelling of the tonsils and pus on the tonsilar surface. The cervical lymph nodes are enlarged and painful to touch.

Treatment is by Penicillin V 500mg bid for 10 days. Erythromycin is an alternative for penicillin allergic individuals at 500mg qid for 10 days.

It is important to note that acute HIV infection may present as an acute pharyngitis.

Viruses such as herpes simplex both type I an II, CMV and EBV may also cause pharyngitis. Candidal pharyngitis is common in the patient whose CD4 count is below 200. Treatment is by use of fluconazole at 200mg per day for 21 days.

Advice the patient to maintain good oral hygiene and to gargle using a mouth wash.

Otitis Externa

This refers to infection of the outer ear canal. S. aureus and Pseudomonas are common causes. The patient presents with ear pain, which is usually very severe. Examination reveals a pustule or carbuncle in the ear cavity. In some instances, the patient may present with a discharge of pus from the ear canal.

Treatment is by use of hypertonic saline solution to clean the ear, an application of antibiotic ear drops.

A severe form of this infection may occur in the setting of severe immunosuppression and spread to the meninges, causing a brain abscess. This is a life threatening condition and requires intravenous antibiotics in high doses for at least 14 days.

Otitis Media

This refers to inner ear infection. It is usually as a result of Eustachian tube dysfunction after an upper respiratory tract infection. It is often a complication of a viral sore throat.

S. pneumonia, H. influenza, M. catarrhalis are all common organisms.

Patients present with ear pain and/or ear discharge (pus). They may also have reduced hearing and may also have fever.

Treatment of this condition with amoxicillin 500mg tid for 5 to 7 days

Lower Respiratory Tract Infections

The lower respiratory tract is a common site of infections in the immunocompromised person. Patients with HIV/AIDS will suffer from a lower respiratory tract infection at least once in their lifetime. At least one-third of patients have a cough lasting over one month at some time during the progression of the disease. In addition:

• Bacterial pneumonia and tuberculosis can occur early in the course of HIV infection at CD4>500;

• Pneumocystis carinii pneumonia (PCP) almost always occurs when the CD4 ................
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